CSHCS CASE MANAGEMENT PLAN OF CARE - Michigan
Health Department
Address:
Address:
Phone:
Fax:
CSHCS County Website:
|Section 1 – Case Information |
|1). Child/Beneficiary CSHCS/ |2). Eligibility Period |3). Child/Beneficiary Name |
|Medicaid ID Number | | |
| | |Male Female |
|4). Date of Birth |5). Address |6). City |7). Zip |
| | | | |
|8). Mother/Guardian |9). Phone: Home: |10). Father/Guardian |
| |Work: | |
| |Cell: | |
|11). Phone |12). Family Email Address: |13). Foster Care/Other |
|Home: | | |
|Work: | | |
|Cell | | |
|14). Alternate Caregiver/ |15). Phone |16). Work |17). Cell |18). Care Coordinator/ Case Manager |
|Relationship | | | | |
| | | | | |
|19). Medical Summary: |
|20). CSHCS Diagnosis(es) {codes with names added} |21). Other Diagnosis(es) {Non CSHCS elig. DX} |
| | |
|22). Other Health Concerns: ; |
|23). Primary Health Care Provider |24). Phone |25). Fax: |26). Email: |
| | | | |
|27). Dentist: |28). Phone |29). Fax: |30). Email: |
| | | | |
|31). Preferred Pharmacy |32). Address |33). Phone |34). Fax: |35). Email: |
| | | | | |
|36). Insurance |
|a. Primary b. Secondary c. MA /FFS d. MA/MHP |
|e. Pharmacy f. Vision g. Dental |
|37). Incontinent Supplier |38). Phone |
|39). Prov. Type |40). Name/ Location: 41). NPI# |42). Phone/Fax: |43). Last Visit |44). Next Visit |
|a. |a. a.|a. |a. |a. |
| | | | | |
|b. | Name/Location: NPI# |Phone/Fax: |Last Visit |Next Visit |
| |b. b.|b. |b. |b. |
| | | | | |
|c. | Name/Location NPI# |Phone/Fax: |Last Visit |Next Visit |
| |c. c.|c. |c. |c. |
| | | | | |
|d. | Name/Location NPI# |Phone/Fax: |Last Visit |Next Visit |
| |d. d. |d. |d. |d. |
| | | | | |
|e. | Name/Location NPI# |Phone/Fax: |Last Visit |Next Visit |
| |e. e. |e. |e. |e. |
| | | | | |
|f. | Name/Location NPI# |Phone/Fax: |Last Visit |Next Visit |
| |f. f.|f. |f. |f. |
| | | | | |
|g. | Name/Location NPI# |Phone/Fax: |Last Visit |Next Visit |
| |g. g. |g. |g. |g. |
| | | | | |
|h. | Name/Location NPI# |Phone/Fax: |Last Visit |Next Visit |
| |h. h. |h. |h. |h. |
| | | | | |
|i. | Name/Location NPI# |Phone/Fax: |Last Visit |Next Visit |
| |i. |i. |i. |i. |
| |i. | | | |
|j. | Name/Location NPI# |Phone/Fax: |Last Visit |Next Visit |
| |j. |j. |j. |j. |
| |j. | | | |
|k. | Name/Location NPI# |Phone/Fax: |Last Visit |Next Visit |
| |k. k. |k. |k. |k. |
| | | | | |
|45). Specialty Care Hospital |46). Phone |47). Fax: |
| | | |
|48). Community Hospital: |49). Phone |50). Fax |
| | | |
|51). CMS Clinic : |52). Phone |53). Fax |
| | | |
|54). Lab: |55). Phone: |56). Fax: |
| | | |
Section 2 - Functional Status and Therapies
|Key : (1) Infant (2) Independent (3) Needs Assistance (4) Dependent N/A=Not Applicable |
|57) Mobility: AMB ( ) W/C ( ) |58) ADLs: Dress ( ) Bath ( ) |
|Transfer ( ) Other ( ) |Toilet ( ) Feed ( ) |
|59) Language/Communication/Sensory Issues: (vision, hearing, speech) |60) Height: Weight: |
| | |
|THERAPIES |
|(School/Community/Private) |
|61) Name/Facility |62)Type of Therapy |63) Treatment Plan |
| | | |
| | | |
| | | |
|64) Comments: |
Section 3 - Areas of Concern: If checked, comment below:
| Allergies Drug Other | Immunizations not UTD per MCIR |
| Cardiovascular | Neurological/Seizures |
| Dental | Skin |
| Endocrine/Metabolic | Sleeping Patterns/ Safe Sleep |
| Gastrointestinal | Upcoming appointments, treatments |
| Genitourinary | Vision |
| Hematological | Other |
| Hearing | |
|65) Comments: |
|66) Medications: |
Section 4 - Equipment & Supplies: Check if Using or Needed
| Apnea Monitor | Gastrostomy Supplies | Positioning Device |
| Air Conditioning | Glucometer | Prosthetics |
| Air Mattress | Hearing Aid | Pulse Oximeter |
| Bath Chair | Hospital Bed | Scale |
| BP Monitor | House Ramp | Shoe Lifts |
| Car/Van Lift | Incontinent Supplies | Stander |
| Car Seat/Booster | IV Therapy | Stroller |
| Cochlear Implant Device | Lifting Device | Suction Machine |
| Commode | Nebulizer/Inhaler | TPN Supplies |
| Communication Device | Orthodontia | Trachestomy Supplies |
| CPAP/BiPAP | Orthotics | Ventilator |
| Diabetic Supplies | Ostomy Supplies | Walker |
| Dialysis Supplies | Oxygen | Wheelchair |
| Eyeglasses | Peak Flow Meter | |
| Feeding Chair | Percussion Vest | |
Section 5 – DME Medical Supplies
|67) DME Provider/ Supplier / Phone |68) Item(s) |69) Due for Replacement |
| | | | |
| | | | |
| | | | |
|70) Comments: |
| |
| |
| |
Section 6 – Education/Psycho-Social
|71) a. School Program: Grade level / Regular / Special Ed |72) Self-concept/ Family Strengths: |
| | |
|b. Contact: | |
|c. Phone: | |
|73) Transportation Method/ Status: |74) Family Support System |
| | |
|75) Current Educational Challenges /Satisfaction(IEP date; 504 plan) |76) Financial Impact |
| | |
|77). Family Status/Summary |
| |
Section 7 – Goals/On-going Care Plan
|78) Date |79) Problem/ Concern |80) Goal |81) Intervention/ |82) Outcome/ Barriers |83) |
| | | |Who will do | |Evaluation/Date |
| | | | | |Resolved |
|a. | | | | | |
|b. | | | | | |
|c. | | | | | |
|d. | | | | | |
• Please review this Plan of Care (POC).
• If there are no changes or corrections, sign this page and return only this page in the enclosed envelope.
• Please call to make changes or corrections.
| Please send a copy to Primary Care Provider: |Date Sent: | |
| Please send a copy to: |Date Sent: | |
|Parent/Legal Guardian/Client Signature | |Date: | |
|Care Coordinator Signature | |Date: | |
Public Heatlh Nurse’s name: Phone:
Completed: in home in office on phone
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Family Center for Children and Youth
with Special Heath Care Needs
Email Address CSHCSFC@
cshcs
Family Phone Line: (800) 359-3722
Poison Control: (800) 222-1222
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